Opinion
[No. S215637.
May 28, 2015.]
SOUTH COAST FRAMING, INC., et al., Petitioners, v. WORKERSâ COMPENSATION APPEALS BOARD, JOVELYN CLARK et al., Respondents.
Counsel
Bradford & Barthel and Louis A. Larres for Petitioners.
Law Offices of Allweiss & McMurty and Michael A. Marks for California Workersâ Compensation Institute as Amicus Curiae on behalf of Petitioners.
No appearance for Respondent Workersâ Compensation Appeals Board.
Law Offices of OâMara & Hampton and Daniel J. Palasciano for Respondent Jovelyn Clark.
Smith & Baltaxe, Bernhard D. Baltaxe; Law Offices of Robert W. Willyard and Robert E. Willyard for California Applicantsâ Attorneys Association as Amicus Curiae on behalf of Respondent Jovelyn Clark.
[MAJORITY â CORRIGAN, J.]
Opinion
CORRIGAN, J.
The family of Brandon Clark was awarded workersâ compensation death benefits after Clark died from the combination of drugs prescribed following a fall at work. The Court of Appeal overturned the award, reasoning there was insufficient evidence that the drugs prescribed for the work injury contributed to the death. We reverse the Court of Appealâs judgment.
I. Background
In September 2008, the 36-year-old Clark fell eight to 10 feet while working as a carpenter for South Coast Framing, Inc. (hereafter the employer). He suffered neck and back injuries as well as a concussion. Clarkâs workersâ compensation doctor prescribed various drugs to treat these injuries, including Elavil (an antidepressant), Neurontin (a neuronal pain reliever), and Vicodin (a codeine-based pain reliever). In January 2009, Clarkâs personal doctor additionally prescribed Xanax (an antianxiety medicine) and Ambien (a sleep aid).
On the morning of July 20, 2009, Clarkâs wife was unable to rouse him and he was pronounced dead at the scene. At the time of his death, Clark had Elavil, Neurontin, Xanax, and Ambien in his blood. Vicodin was detected in his urine. The autopsy surgeon concluded the death was accidental and âis best attributed to the combined toxic effects of the four sedating drugs detected in his blood with associated early pneumonia.â The first two medications were prescribed by the workersâ compensation physician. There was no dispute that Clark died as a result of the combined effects of some of the drugs he took. The dispute centered around which drugs played a role, how big that role was, and why the drugs were prescribed.
Clarkâs wife, Jovelyn, and their three minor children (hereafter the family) sought death benefits, arguing medications prescribed for Clarkâs industrial injury caused his death. Jovelyn stated at her deposition that Clarkâs personal doctor had prescribed Ambien because Clark was having trouble sleeping. Before the accident, Clark had sometimes taken Tylenol PM to help him sleep. Clairkâs physician prescribed Xanax for an anxiety attack suffered just before an unrelated surgical procedure. Clark also received epidural shots from his workersâ compensation doctor to alleviate continuing neck and back pain. Shortly after the second epidural injection, Clark complained to his wife and brother that he would experience âblackoutâ episodes. Clark continued to suffer from pain, which had gotten progressively worse and was not relieved by the injections.
Dr. Daniel J. Bressler concluded Clark died of an accidental drug overdose. His supplemental report stated that â[t]he specific combination of medicines he was on, which included Xanax, Ambien, Flexeril, Neurontin, [Elavil], and [Vicodin], all separately and in combination had the capacity to induce respiratory depression, and even respiratory arrest.â Bressler also found that Clarkâs reports to his wife and brother of âaltered states of consciousnessâ were âprobably . . . warning episodes of untoward synergistic respiratory depression and/or central nervous system depression prior to the date of death.â
The parties agreed upon Dr. Thomas C. Bruff as a qualified medical examiner. Bruff reported that Neurontin âdid not have a role in this particular caseâ and Elavil âwas prescribed in such low dose, and blood levels show that the medication was likely taken as prescribed.â Bruff concluded: âHowever, [Ambien] and [Xanax] [prescribed by Clarkâs personal physician] [were] found in excess of what would be normally considered peripheral blood concentrations. Both these medications work in a similar fashion and would be considered at least additive in their effects. It is my opinion . . . that it is just this additive effect of [Ambien] and [Xanax] that caused sedation significant enough to result in the events leading to [Clarkâs] death.â Thus, Bruffâs report concluded that Clarkâs overdose was caused solely by medications prescribed by his personal doctor and not his workersâ compensation physician.
Dr. Bruffâs subsequent deposition testimony retreated somewhat from his report. Bruff maintained that Neurontin played no role in Clarkâs death. However, he testified that Elavil âmay have had a small role at the levels found.â Although he believed Ambien and Xanax had âmore weight,â he could not âabsolutely slam the door and say [Elavil] had no effect.â Clarkâs Elavil level was elevated for his prescription level but insufficient to be fatal as the sole or predominant cause of death. When asked if Elavil, in combination with Ambien and Xanax, could have âcontributedâ to Clarkâs death, Bruff answered, âitâs possibleâ and that Elavil âcould be an incremental contributor,â although âthe [Xanax] and [Ambien] being in the same class and at a much higher dose . . . kind of carried the day.â Bruff reiterated that Elavil was âway down thereâ as a cause of death and it would be âreally speculativeâ to place a percentage on it. When asked if Elavil âmight have been what just put it over the edgeâ to cause Clarkâs death, Bruff agreed it was possible but â[t]he exact amount is way down thereâ and âwe literally are dancing about the minimum level of causation . . . .â Bruff acknowledged Elavil was âadditiveâ and part of the causation âpie,â but he could not assign a number reflecting the percentage of causation attributable to it, suggesting âit would be closing your eyes and throwing a dart at a dartboard kind of stuffâ or âjust pulling numbers out of the sky.â When asked again to assign a number, Bruff responded â[w]eâre looking at one percent causation and weâre dangling right down there,â but it would be âmedically improper to sit here and say that I can pull a percentage out.â He acknowledged, âItâs not zero, but itâs certainly not twenty percent either, where itâs a no brainer.â Bruff noted Vicodin was detected in Clarkâs urine, but not blood. Asked if Vicodin could have contributed to the death, Bruff stated âitâs potentially a cause, but itâs so minuscule, itâs like you have a big twelve inch pie and a couple little crumbs off the crust are due to the Vicodin. You wouldnât even notice it if you served up the pie, having two little flakes gone.â
There was conflicting evidence as to why Clarkâs physician prescribed Ambien. His wife testified he had taken Tylenol PM before the accident to help him sleep, but after the fall the Tylenol PM was not working. The physician noted, however, that Clark was not in pain when he had trouble sleeping.
The workersâ compensation judge (WCJ) awarded death benefits to the family, finding Clarkâs death resulted âdue to the medications he was taking for his industrial admitted injury.â The WCJ explained, âit is clear that the [Elavil] prescribed by the doctors for the industrial injury as well as the [Vicodin] acted as concurring causes such that, even without the liberal construction of Labor Code § 3202, the death of BRANDON CLARK was a result of the original industrial injury . . . .â The WCJ further found âthat the applicant was suffering from continued or chronic pain from his industrial neck, back and head injury and that he was having difficulty sleeping because of that pain,â and that âthe doctors prescribed him both the Ambien . . . and the [Xanax] for the inability to sleep.â
The employer petitioned the Workersâ Compensation Appeals Board (Board) for reconsideration, arguing no substantial evidence supported the WCJâs causation finding. The WCJ issued a report recommending the petition be denied. The Board adopted the WCJâs report and denied reconsideration. The Court of Appeal granted the employerâs petition for writ of review and reversed. We granted the familyâs petition for review.
II. Discussion
Labor Code section 3600, subdivision (a) provides that workersâ compensation liability âshall, without regard to negligence, exist against an employer for any injury sustained by his or her employees arising out of and in the course of the employment and for the death of any employee if the injury proximately causes death.â â âThe requirement of Labor Code section 3600 is twofold. On the one hand, the injury must occur âin the course of the employment.â This concept âordinarily refers to the time, place, and circumstances under which the injury occurs.â [Citation.] . . .â [Citation.] [¶] âOn the other hand, the statute requires that an injury âarise out ofâ the employment .... It has long been settled that for an injury to âarise out of the employmentâ it must âoccur by reason of a condition or incident of [the] employment. . . .â [Citation.] That is, the employment and the injury must be linked in some causal fashion.â â (LaTourette v. Workersâ Comp. Appeals Bd. (1998) 17 Cal.4th 644, 651 [72 Cal.Rptr.2d 217, 951 P.2d 1184] (LaTourette), quoting Maher v. Workersâ Comp. Appeals Bd. (1983) 33 Cal.3d 729, 733-734 [190 Cal.Rptr. 904, 661 P.2d 1058] (Maher).) âThe applicant for workersâ compensation benefits has the burden of establishing the âreasonable probability of industrial causation.â â (LaTourette, at p. 650, quoting McAllister v. Workmenâs Comp. App. Bd. (1968) 69 Cal.2d 408, 413 [71 Cal.Rptr. 697, 445 P.2d 313] (McAllister).) If the injury causes death, the workerâs dependents are entitled to a death benefit. (§ 4701, subd. (b).) As discussed post, workersâ compensation liability may also encompass a subsequent nonindustrial injury or death attributable to the initial industrial accident.
The question here is the required nature and strength of the causal link between the industrial injury and death. Tort law and the workersâ compensation system are significantly different. One result of the difference is the role and application of causation principles. â[Ajlthough Labor Code section 3600 refers to âproximate cause,â its definition in workersâ compensation cases is not identical to that found in the common law of torts. [Citation.] âIn fact, the proximate cause requirement of Labor Code section 3600 has been interpreted as merely elaborating on the general requirement that the injury arise out of the employment.â [Citation.] The danger from which the employeeâs injury results must be one to which he was exposed in his employment. [Citation.] â âAll that is required is that the employment be one of the contributing causes without which the injury would not have occurred.â â [Citation.]â (LaTourette, supra, 17 Cal.4th at p. 651, fn. 1, quoting Maher, supra, 33 Cal.3d at p. 734, fn. 3.)
Legal causation in tort law has traditionally required two elements: cause in fact and proximate cause. âAn act is a cause in fact if it is a necessary antecedent of an event.â (PPG Industries, Inc. v. Transamerica Ins. Co. (1999) 20 Cal.4th 310, 315 [84 Cal.Rptr.2d 455, 975 P.2d 652].) This has traditionally been expressed as the â âbut forâ â test, i.e., if the injury âwould have happened anyway, whether the defendant was negligent or not, then his or her negligence was not a cause in fact.â (6 Witkin, Summary of Cal. Law (10th ed. 2005) Torts, § 1185, p. 552; see Viner v. Sweet (2003) 30 Cal.4th 1232, 1239-1240 [135 Cal.Rptr.2d 629, 70 P.3d 1046].) âCalifornia has definitively adopted the substantial factor test of the Restatement Second of Torts for cause-in-fact determinations. [Citation.] Under that standard, a cause in fact is something that is a substantial factor in bringing about the injury.â (Rutherford v. Owens-Illinois, Inc. (1997) 16 Cal.4th 953, 968-969 [67 Cal.Rptr.2d 16, 941 P.2d 1203].) â[T]he âsubstantial factorâ test subsumes the âbut forâ test.â (Mitchell v. Gonzales (1991) 54 Cal.3d 1041, 1052 [1 Cal.Rptr.2d 913, 819 P.2d 872]; see Viner, at p. 1240.) â âThe substantial factor standard is a relatively broad one, requiring only that the contribution of the individual cause be more than negligible or theoretical.â [Citation.] Thus, âa force which plays only an âinfinitesimalâ or âtheoreticalâ part in bringing about injury, damage, or loss is not a substantial factorâ [citation], but a very minor force that does cause harm is a substantial factor [citation]. This rule honors the principle of comparative fault.â (Bockrath v. Aldrich Chemical Co. (1999) 21 Cal.4th 71, 79 [86 Cal.Rptr.2d 846, 980 P.2d 398]; see 6 Witkin, Summary of Cal. Law, supra, Torts, § 1193, p. 568.)
On the other hand, the workersâ compensation system is not based upon fault. âIt seeks (1) to ensure that the cost of industrial injuries will be part of the cost of goods rather than a burden on society, (2) to guarantee prompt, limited compensation for an employeeâs work injuries, regardless of fault, as an inevitable cost of production, (3) to spur increased industrial safety, and (4) in return, to insulate the employer from tort liability for his employeesâ injuries.â (S. G. Borello & Sons, Inc. v. Department of Industrial Relations (1989) 48 Cal.3d 341, 354 [256 Cal.Rptr. 543, 769 P.2d 399]; see Cal. Const., art. XIV, § 4; Chevron U.S.A., Inc. v. Workersâ Comp. Appeals Bd. (1999) 19 Cal.4th 1182, 1189 [81 Cal.Rptr.2d 521, 969 P.2d 613].) Accordingly, â[t]he statutory proximate cause language [of section 3600] has been held to be less restrictive than that used in tort law, because of the statutory policy set forth in the Labor Code favoring awards of employee benefits. In general, for the purposes of the causation requirement in workersâ compensation, it is sufficient if the connection between work and the injury be a contributing cause of the injury . . . .â (Nash v. Workersâ Comp. Appeals Bd. (1994) 24 Cal.App.4th 1793, 1809 [30 Cal.Rptr.2d 454]; see LaTourette, supra, 17 Cal.4th at p. 651, fn. 1; Maher, supra, 33 Cal.3d at p. 734, fn. 3; see also § 3202.)
The Court of Appeal reversed the WCJâs factual finding of proximate cause here, concluding no substantial evidence supported the finding. The court reasoned that Dr. Bruffâs deposition testimony, even if considered a change of opinion from his earlier report, âwas largely based on surmise, speculation, conjecture and guess,â noting that he could not place a percentage figure approximating the level of causation attributable to the âindustrially prescribedâ medications. The Court of Appeal reasoned: âHere, Dr. Bruff admitted that it is difficult to make a âreasonable medical analysisâ regarding [Elavilâs] precise contribution to Brandonâs death. He also stated that making that kind of determination âreally gets to be speculative.â Liberally construing Dr. Bruffâs testimony and report in its totality, we conclude the evidence did not establish industrial causation. Rather, the evidence demonstrates that if [Elavil] played a role at all, it was not significant such that it constituted a material factor contributing to Brandonâs death.â (Italics added.)
The Court of Appeal thus concluded that, although Elavil âplayed a roleâ in Clarkâs death, it was insufficient to prove proximate causation because it was not sufficiently âsignificantâ or a âmaterial factor.â This analysis fails to honor the difference between tort law principles and the application of the workersâ compensation scheme. Tort liability only attaches if the defendantâs negligence was a significant or substantial factor in causing injury. In the workersâ compensation system, the industrial injury need only be a contributing cause to the disability.
In states that permit it, tort law mitigates liability by recognizing comparative fault. A defendantâs liability may be reduced by the degree to which a plaintiffâs own negligence contributed to the injury. Under workersâ compensation, generally, liability is mitigated by apportioning monetary compensation to the degree that an industrial injury contributed to the disability. However, as we discuss later, apportionment is not applied in death claims.
We have recognized the contributing cause standard since the very beginning of the workersâ compensation scheme. In Kimbol v. Industrial Acc. Commission (1916) 173 Cal. 351 [160 P. 150], we adopted the definition of â âarising out of the employmentâ â given by the Supreme Judicial Court of Massachusetts: ââ[The injury] arises out of the employment when there is apparent to the rational mind, upon consideration of all the circumstances, a causal connection between the conditions under which the work is required to be performed and the resulting injury. Under this test, if the injury can be seen to have followed as a natural incident of the work and to have been contemplated by a reasonable person familiar with the whole situation as a result of the exposure occasioned by the nature of the employment, then it arises âout ofâ the employment. But it excludes an injury which cannot fairly be traced to the employment as a contributing proximate cause and which comes from a hazard to which the workman would be equally exposed apart from the employment.â â (Id. at p. 353, italics added, quoting In re McNicol (1913) 215 Mass. 497 [102 N.E. 697].)
Contributing proximate cause within the meaning of Kimbol has been applied more broadly in the workersâ compensation context than in tort law. Death attributable to both industrial and nonindustrial causes may support a death claim, and industrial causation has been shown in an array of scenarios where a work injury contributes to a subsequent nonindustrial injury. An employee is entitled to compensation if a new or aggravated injury results from medical or surgical treatment for an industrial injury. (Fitzpatrick v. Fidelity & Casualty Co. (1936) 7 Cal.2d 230, 233-234 [60 P.2d 276]; Georgia Casualty Co. v. Indus. Acc. Com. (1927) 87 Cal.App. 333, 334-335 [262 P. 394] [death from anesthetic]; see Maher, supra, 33 Cal.3d at pp. 735-738 [adverse drug reaction when treatment was required for employment]; Ballard v. Workmenâs Comp. App. Bd. (1971) 3 Cal.3d 832, 837-839 [92 Cal.Rptr. 1, 478 P.2d 937] (Ballard) [drug addiction to prescribed pain medication].) Causation may also be shown if an industrial injury contributes to a later nonindustrial accident or injury. (See Lundberg v. Workmenâs Comp. App. Bd. (1968) 69 Cal.2d 436, 439-441 [71 Cal.Rptr. 684, 445 P.2d 300] [industrial back injury contributed to later ruptured disc]; Ferreira v. Workmenâs Comp. Appeals Bd. (1974) 38 Cal.App.3d 120, 124 â 126 [112 Cal.Rptr. 232] (Ferreira) [hernia suffered at work contributed to later hernia suffered at home]; State Comp. Ins. Fund v. Ind. Acc. Com. (1959) 176 Cal.App.2d 10, 13-21 [1 Cal.Rptr. 73] (State Comp. Ins. Fund) [carpenterâs industrial eye injury contributed to later nonindustrial accident while using a saw at home].) Indeed, even a workerâs suicide may be compensable if an industrial injury contributed to it. (See Chu v. Workersâ Comp. Appeals Bd. (1996) 49 Cal.App.4th 1176, 1181-1185 [57 Cal.Rptr.2d 221]; Burnight v. Industrial Acc. Com. (1960) 181 Cal.App.2d 816, 820-829 [5 Cal.Rptr. 786].)
A corollary of the no-fault principles of workersâ compensation is that âan employer takes the employee as he finds him at the time of the employment.â (Ballard, supra, 3 Cal.3d at p. 837; Maher, supra, 33 Cal.3d at p. 734; G. L. Eastman Co. v. Industrial Acc. Com. (1921) 186 Cal. 587, 597 [200 P. 17] (Eastman Co.).) Thus, âan employee may not be denied compensation merely because his physical condition was such that he sustained a disability which a person of stronger constitution or in better health would not have suffered.â (Duthie v. Workersâ Comp. Appeals Bd. (1978) 86 Cal.App.3d 721, 727 [150 Cal.Rptr. 530]; see Maher, at p. 734.)
Further, âthe acceleration, aggravation or âlighting upâ of a preexisting disease is an injury in the occupation causing the same.â (Tanenbaum v. Industrial Acc. Com. (1935) 4 Cal.2d 615, 617 [52 P.2d 215]; see Brodie v. Workersâ Comp. Appeals Bd. (2007) 40 Cal.4th 1313, 1326 [57 Cal.Rptr.3d 644, 156 P.3d 1100]; Ballard, supra, 3 Cal.3d at p. 837; Eastman Co., supra, 186 Cal. at p. 594; see also Industrial Indem. Exch. v. Ind. Acc. Com. (1948) 87 Cal.App.2d 465, 467-470 [197 P.2d 75] [miner died from dust exposure at his last workplace, even though similarly exposed at previous worksites].) On this point, McAllister, supra, 69 Cal.2d 408 and Ballard, supra, 3 Cal.3d 832 are instructive. McAllister affirmed the award of a death benefit to the wife of a firefighter who died of lung cancer. Substantial evidence established the firefighter had inhaled toxic smoke throughout his 32 years of service, causing his cancer. McAllister rejected the argument that the claim should have been denied because the firefighter also âsmoked about a pack of cigarettes a day for some 42 years.â (McAllister, at p. 418.) McAllister noted that âthe more smoke decedent inhaled â from whatever source â the greater the danger of his contracting lung cancer. His smoking increased that danger, just as did his employment. Given the present state of medical knowledge, we cannot say whether it was the employment or the cigarettes which âactuallyâ caused the disease; we can only recognize that both contributed substantially to the likelihood of his contracting lung cancer. As we noted, however, in Employers etc. Ins. Co. v. Industrial Acc. Com. (1953) 41 Cal.2d 676, 680 [263 P.2d 4], the decedentâs employment need only be a âcontributing causeâ of his injury. And in Bethlehem Steel Co. v. Industrial Acc. Com. [(1943)] 21 Cal.2d 742, 744 [135 P.3d 153], we pointed out a particular instance of this principle when we stated that it was enough that âthe employeeâs risk of contracting the disease by virtue of the employment must be materially greater than that of the general public.â Thus in Bethlehem we allowed an award to an employee who contracted a contagious eye disease, since he had shown that the disease was more common at his place of employrfient than among the public. [¶] Although decedentâs smoking may have been inadvisable, respondents offer no reason to believe that the likelihood of contracting lung cancer from the smoking was so great that the danger could not have been materially increased by exposure to the smoke produced by burning buildings.â (Id. at pp. 418-419.)
In Ballard, a secretary suffered a back injury at work and was prescribed pain medication. Having a â âlow tolerance for pain of any kind,â â she took more than her prescribed dosages and became addicted. (Ballard, supra, 3 Cal.3d at p. 835.) Further, she sought out illegal drugs and became addicted to those as well. The referee denied her workersâ compensation claim, concluding that â â[t]he most likely cause of her addiction is the obvious life-long neurotic personality problems and the injury simply serves to provide a rationalization for her recourse to drugs.â â (Id. at p. 837.) Ballard reversed, reasoning that the refereeâs findings did not âserve to warrant denial of recovery if the addiction resulted in part from the prescribed drugs. The employer takes the employee as he finds him at the time of employment. Similarly, the finding that her problems would have culminated in addiction âeven in the absence of this trauma and the treatment rendered thereafterâ do[es] not furnish a basis for denial for all recovery because even in cases where disability would follow from the normal progress of the preexisting disease^] apportionment is proper where the industrial injury has contributed to the disability. There is no finding that the prescribed drugs did not, along with the personality problems and the illegally obtained drugs, contribute to any part of the disability, and the findings do not support the denial of recovery.â (Id. at p. 838, italics added.) Ballard concluded: âThe decisive question is not whether her actions in illegally obtaining drugs were a causative factor or contributed to her disability; the question is not whether it was appropriate for the doctors to prescribe drugs for her or whether they were to âblameâ; under the authorities discussed above, the question is whether the prescribed drugs were a causative factor in her present disability. Dr. Malitz nowhere states that her present condition was caused solely by her personality disorder and the unlawfully obtained drugs or that her present condition would have occurred absent the industrial injury and the prescribed drugs.â (Id. at pp. 838-839; see Lamb v. Workmenâs Comp. Appeals Bd. (1974) 11 Cal.3d 274, 279-283 [113 Cal.Rptr. 162, 520 P.2d 978] [reversing the Boardâs reversal of death benefit where work stress caused hypertension leading to death from heart disease].) Mark v. Industrial Acc. Com. (1938) 29 Cal.App.2d 495 [84 P.2d 1071] upheld a death benefit award where a worker died of heart occlusion. The opinion observed: âAssuming, if necessary, that decedent was afflicted with a weak and somewhat devitalized heart, that in itself is not determinative of the question here. If deceased was afflicted with such a condition and thereafter subjected himself to violent exertion and extraordinary strain in the course of his employment which caused his death sooner than he otherwise might have suffered, his dependents are entitled to compensation.â (Id. at pp. 500-501, italics added.)
Whether an industrial injury proximately causes a later injury or death within the meaning of section 3600 is a question of fact. (See Head Drilling Co. v. Industrial Acc. Com. (1918) 177 Cal. 194, 197 [170 P. 157]; Smith v. Workersâ Comp. Appeals Bd. (1981) 123 Cal.App.3d 763, 773 [176 Cal.Rptr. 843].) âJudicial review of the Boardâs decision on factual matters is limited to determining whether the decision, based on the entire record, is supported by substantial evidence.â (Guerra v. Workersâ Comp. Appeals Bd. (1985) 168 Cal.App.3d 195, 199 [214 Cal.Rptr. 58]; see State Comp. Ins. Fund, supra, 176 Cal.App.2d at pp. 13-14.) In this context, judicial review has been expressly limited by statute to whether the award âwas not supported by substantial evidenceâ and the factual findings âsupport the . . . award.â (§ 5952, subds. (d), (e).) Indeed, section 5952 expressly provides that â[nothing in this section shall permit the court ... to exercise its independent judgment on the evidence.â
The WCJâs findings of fact, and the Boardâs adoption of them, âare final and conclusive and not subject to appellate review if supported by substantial evidence in light of the entire record. [Citations.] Substantial evidence must be reasonable in nature, credible, and of solid value such that a reasonable mind might accept it as adequate to support a conclusion. [Citation.] In examining the entire record, this court âmay not simply isolate evidence which supports or disapproves the boardâs conclusions and ignore other relevant facts which rebut or explain the supporting evidence ....ââ (County of Kern v. Workersâ Comp. Appeals Bd. (2011) 200 Cal.App.4th 509, 516-517 [132 Cal.Rptr.3d 621]; see Braewood Convalescent Hospital v. Workersâ Comp. Appeals Bd. (1983) 34 Cal.3d 159, 164 [193 Cal.Rptr. 157, 666 P.2d 14].)
Substantial evidence supported the WCJâs finding that Elavil and Vicodin, prescribed for Clarkâs industrial injury, contributed to his death. While the level of Elavil could not have been independently fatal, Dr. Bruff testified that it had a contributory effect. As noted, Bruff testified Elavil âmay have had a small role at the levels found,â âcould be an incremental contributor,â and was âadditive.â Although he could not assign an exact percentage of contribution, Bruff affirmed â[i]tâs not zero . . . .â He further agreed with plaintiffsâ counselâs statement that â[w]e canât rule out that the [Elavil] might have been what just put it over the edge to cause this poor manâs death at thirty-[six] years old.â Even if it was possible that Clark might have died from an overdose of Xanax and Ambien alone, there also existed a reasonable probability that the Elavil made Clarkâs death more likely. Similarly with respect to Vicodin, Dr. Bressler stated in his report that the âspecific combination of medicinesâ Clark had ingested, including Vicodin, âall separately and in combination had the capacity to induce respiratory depression, and even respiratory arrest.â Bressler further reasoned that Clarkâs reports of blacking out showed these drugs caused âuntoward synergistic respiratory depression and/or central nervous system depression prior to the date of death.â Thus, Bressler not only concluded that the drugs could have caused Clarkâs death, but contributed to a respiratory or nervous system condition that ultimately led to his demise. Bruff testified Vicodin was âpotentially a causeâ and stated âitâs like you have a big twelve inch pie and a couple little crumbs off the crust are due to the Vicodin.â This testimony referenced Bruffâs earlier statements concerning the causation âpieâ and appeared to concede that Vicodin was, in fact, part of that âpie.â
This situation is analogous to that of the cigarette-smoking firefighter in McAllister and the addiction-prone secretary in Ballard. In light of the evidence, the WCJ could reasonably find that Elavil and Vicodin increased the likelihood of death by drug overdose. Under these circumstances, those two drugs could be found to have contributed to Clarkâs death within the meaning of section 3600. This factual issue was resolved by the WCJ. The evidence on this point was not overwhelming. However, the WCJ resolved the question in favor of the claimant. The Court of Appeal is not free to reweigh the evidence or substitute an inapplicable standard of review.
As noted, in concluding there was no substantial evidence of causation, the Court of Appeal reasoned that if Elavil âplayed a role at all, it was not significant such that it constituted a material factor contributing to Brandonâs death.â In support of its application of a âmaterial factorâ standard, the Court of Appeal cited only a single practice guide. In describing the necessary proof of causation in a death case, the practice guide stated; â[T]he industrial injury need not be the sole cause of the employeeâs death to qualify the employeeâs dependents for death benefits. So long as the industrial injury and employment generally constituted material factors in contributing to the employeeâs death, the proximate cause test of LC § 3600 is met.â (1 Dobrin et al., Cal. Workersâ Compensation Law and Practice (6th ed. 2014) § 11:04, p. 11-4.) For this proposition, the practice guide cites only Pacific Gas & Elec. Co. v. Ind. Acc. Com. (1961) 56 Cal.2d 219, 221-223 [14 Cal.Rptr. 548, 363 P.2d 548] (Pacific Gas & Elec.). (See 1 Dobrin et al., supra, § 6:10, p. 6-6 [applicant must show âsome material contribution of the employment to the condition or deathâ].)
Pacific Gas & Elec. lends no support for a material factor standard that is different from, or more stringent than, the contributing cause standard often articulated in our precedents. Indeed, PG&E did not involve a question of causation at all, and at no time employed the term âmaterial.â In that case, the worker, who had a preexisting nonindustrial carcinoma, suffered a back injury at work. The worker later died and his family was awarded a death benefit. The evidence established that âwhile the industrial injury brought about the death sooner than it would otherwise have occurred, and was thus one of the proximate causes of death, if there had been no injury the carcinoma would of itself probably have resulted in the employeeâs death within a year after its actual occurrence.â (Pacific Gas & Elec., supra, 56 Cal.2d at p. 221.) The employer did not âquestion the finding that the industrial injury was a proximate cause of the death or that the dependents were for that reason entitled to an award of death benefitsâ (ibid.), and the sole issue was whether the death benefits must be apportioned between the industrial and nonindustrial causes. Pacific Gas & Elec. concluded death benefits were not apportionable.
While some older cases have used the phrase âmaterially contributeâ in passing, they have in no way suggested they were employing a different test from the contributing cause standard recognized in Kimbol. For example, in Travelers Ins. Co. v. Ind. Acc. Com. (1949) 33 Cal.2d 685 [203 P.2d 747], we upheld a death benefit where the worker died of meningitis. The question was whether industrial lead poisoning contributed to the death, either by causing the disease itself or by accelerating its effect. The court concluded substantial evidence supported the award: âReading the physicianâs testimony as a whole, it clearly appears that, as a scientist, in view of the impossibility of testing the blood at the autopsy, he was unwilling to state as a certainty that Odello had lead poisoning; on the other hand, in view of the evidence of lead deposits in Odelloâs body and the symptoms related by his wife, it was the doctorâs opinion that lead poisoning could not be ruled out as a contributing cause of death. . . . Considering the testimony of Dr. Duggan as a whole, the trier of fact reasonably could find that, in the physicianâs opinion, Odello probably was suffering from lead poisoning at the time he contracted meningitis and such poisoning was a material contributing cause of death.â (Id. at pp. 687-688, italics added.) At least two other cases have made similar statements in passing. (See Ferreira, supra, 38 Cal.App.3d at p. 126; Industrial Indem. Co. v. Ind. Acc. Com. (1949) 90 Cal.App.2d 262, 263, 265 [202 P.2d 585].)
None of these cases expressly considered or decided the issue of what causation standard applied and, thus, cannot be read as creating a higher causation level than the long-established contributing cause test of Kimbol. The Court of Appeal reasoned that even if Elavil âplayed a roleâ in Clarkâs death, the evidence of causation was insubstantial because âit was not significant such that it constituted a material factor contributingâ to his death. In doing so, it appeared to use the term âmaterialâ as a further substantive hurdle in determining whether a work injury was a contributing cause of death. No authority supports such use
The Court of Appealâs analysis emphasized Dr. Bruffâs inability to offer a precise percentage figure for Elavilâs contribution to Clarkâs death. In rejecting a similar argument, McAllister reasoned: âOf course, such a detailed account would have been desirable, but it was not a prerequisite to recovery. Such a burden on applicants would often be unbearable. The exact amount and kinds of pollutants inhaled by decedent could only be known if a chemist had gone with him to each fire over his 32 years as a fireman. The precise toxicity of each type of pollutant, alone or in combination with others, is still not known.â (McAllister, supra, 69 Cal.2d at p. 417.) The court thus reasoned that â[i]n order to cover such unavoidable uncertainties, we require applicants to establish no more than that industrial causation is reasonably probable.â (Ibid.)
That standard was met here. The autopsy and Dr. Bresslerâs report both attributed the cause of Clarkâs death to the combination of all sedative drugs in Clarkâs system. Bressler concluded that all of these drugs âseparately and in combination had the capacity to induce respiratory depression, and even respiratory arrest.â Even while repeatedly minimizing Elavilâs contribution to the death, Dr. Bruff also repeatedly agreed that it could have combined with the effects of the other drugs to cause death. Under these circumstances, Bruffâs failure to provide a precise percentage for Elavilâs contribution did not render evidence of causation insubstantial. As discussed, substantial evidence reflected that both Elavil and Vicodin contributed to Clarkâs death.
The WCJ alternatively found industrial causation because Clarkâs personal doctor prescribed Ambien to address his inability to sleep due to the pain from his work injury. There is no dispute that Ambien contributed to Clarkâs death. Dr. Bruff reported that the Ambien level in Clarkâs body was â10 to 15 times higher than normal dosage levelsâ and concluded that âthis additive effect of [Ambien] and [Xanax] . . . caused sedation significant enough to result in the events leading to his death.â Clarkâs wife testified Clark took Ambien because he had trouble sleeping. Before receiving his Ambien prescription, Clark told his workersâ compensation doctor that he âuses the pain medication mostly at night to help him get comfortable for sleep.â It is undisputed that Clark continued to experience pain, ultimately receiving two epidural injections in an attempt to mitigate these symptoms. Those injections caused âblacking out,â which Dr. Bressler described as probable warning episodes of âuntoward synergistic respiratory depression.â
Substantial evidence supported this alternative finding as well. As noted, injury or death resulting from medical treatment of a work injury is compensable, and â[t]his rule applies whether the treatment is provided by a physician selected by the employee or by the employer or the employerâs compensation carrier.â (1 Hanna, Cal. Law of Employee Injuries and Workersâ Compensation (rev. 2d ed. 2015) Injuries From Employerâs Medical Treatment, § 4.66[l][a], p. 4-88 (rel. 75-4/2012).) Again, the evidence is open to interpretation. However, on the present record, the WCJ could reasonably conclude that Clark could not sleep because his injury caused discomfort. Accordingly, his prescription for Ambien, and his later drug overdose, were causally related to his work injury. (See Maher, supra, 33 Cal.3d at pp. 735-738; Ballard, supra, 3 Cal.3d at pp. 837-839.)
In conclusion, our Constitution vests the Legislature âwith plenary power ... to create, and enforce a complete system of workersâ compensation.â (Cal. Const., art. XIV, § 4.) It is within the Legislatureâs exclusive province to specify the causation standard required for compensation. The Legislature has not articulated a more stringent standard for death claims than disability claims. (See § 3600, subd. (a).) As Pacific Gas & Elec. reasoned, âit is not the function of a court to extend legislative provisions into a field to which it appears plainly that the Legislature has chosen not to make them applicable.â (Pacific Gas & Elec., supra, 56 Cal.2d at p. 222; see Sumner v. Workersâ Comp. Appeals Bd. (1983) 33 Cal.3d 965, 973, fn. 11 [191 Cal.Rptr. 811, 663 P.2d 534].) Similarly, we may not break from long-standing precedent to apply a higher proximate cause standard to death cases when the Legislature has not seen fit to do so.
III. Disposition
We reverse the Court of Appealâs judgment.
Cantil-Sakauye, C. 1, Werdegar, L, Chin, L, Liu, L, Cuéllar, L, and Kruger, J., concurred.
Both the medical experts and the workersâ compensation judge used brand names and chemical names of drugs interchangeably. For consistency, we use the brand names. The chemical names are shown in parentheses: Elavil (amitriptyline), Neurontin (gabapentin), Vicodin (hydrocodone), Xanax (alprazolam), and Ambien (zolpidem).
Subsequent statutory references will be to the Labor Code unless noted.
The Court of Appeal actually quotes from an earlier edition of the practice guide (Dobrin), but the relevant portion has not been changed between editions.
The employer cites two workersâ compensation case summaries that employ the phrase âmaterial factor.â (See West v. Workersâ Comp. Appeals Bd. (1998) 63 Cal.Comp.Cases 1203; Fickes v. Workersâ Comp. Appeals Bd. (1983) 48 Cal.Comp.Cases 484.) The persuasive value of such summaries is debatable. As the court in County of San Bernardino v. Workersâ Comp. Appeals Bd. (2012) 203 Cal.App.4th 1469 [138 Cal.Rptr.3d 328] observed, such decisions âhave no precedential value in any caseâ but may be cited âto the extent that they point out the contemporaneous interpretation and application of the workersâ compensation laws by the Board.â (Id. at p. 1473, fn. 2.) Even so, they are no more illuminating than the cited cases. They include no citation to authority, use the phrase in passing, and do not include the Boardâs relevant reasoning.